Aviation's Gift to Health Care

Nov. 16, 2005

It was during the fogbound afternoon of March 27, 1977, on Tenerife in the Canary Islands, that a revolution in both aviation and medical safety began with a single human error: a Boeing 747 captain's mistaken assumption that a critical pre-flight step had been performed.

The first and second officers almost caught the mistake. But rather than stop the process, the two other crew members convinced themselves that the captain (who was the chief pilot of KLM Royal Dutch Airlines) was too senior and too good to be wrong. Captain Jacob Van Zanten couldn't possibly be starting a takeoff roll with a half-million pound airliner in thick fog without first obtaining the takeoff clearance from the control tower, and without the assurance that the unseen runway ahead was clear of other aircraft.

But Van Zanten had forgotten about the clearance in his haste to get under way.

Without the benefit of hearing his subordinates' concerns, the captain accelerated down the fog-shrouded runway only to break out just in time to find a Pan American 747 sitting sideways on the runway just ahead. Too fast to stop, too slow to fly over the other jumbo, the two huge aircraft collided, killing 582 people in the worst airline accident in aviation history. Only a few aboard the Pan Am jet escaped with their lives. No one -- including Van Zanten -- survived aboard the KLM plane.

No negligence, no carelessness, no incompetence caused the disaster. Instead, the accident arose from the simple truth that even a chief pilot -- even one of the best airline pilots on the planet -- could make a human mistake that the "system" should have been able to catch in time.

Aviation Changes Reach Medical Field

The Tenerife disaster forever changed aviation's approach to safety by sparking a revolution in the way pilots cooperate and openly communicate with each other -- and that revolution is the prime reason we have now passed four years without a major airline accident in the United States. In many respects, those 582 lives were not lost in vain, since the lessons learned have been thoroughly applied to save countless others in aviation, and now in medicine!

Medicine?

In the past fifteen years, the principles of teamwork and communication and recognition of the eternal propensity for human failure so glaringly illuminated on that debris-strewn runway at Tenerife have begun to be adopted by physicians and nurses and pharmacists as American health care comes to grips with the critical need for its own safety revolution.

Traditionally, doctors have been trained to expect themselves to perform without error and without the need for anyone else's advice, and that model is simply dangerous, cutting off vital information, assuming nonexistent perfection, and creating a national cottage industry of talented mavericks wholly unsupported and unable to benefit from the mistakes of others.

In short, while airline flying has become a low-risk industry and literally the safest method of travel, health care (in terms of the possibility of being unnecessarily injured by medical mistake) is very high-risk -- and not just because hospitals tend to attract sick people.